January 1979

26 The Journal o f P E D I A T R I C S

Percentile curves for hemoglobin and red cell

volume in infancy and childhood

Percentile curves were calculated for hemoglobin and mean corpuscular volume in children between 0.5
and 16 years of age. The curves were derived from several populations of non-indigent white children
who lived near sea level Subjects were excluded from the reference population if they had laboratory
evidence of iron deficiency, thalassemia minor, and/or hemoglobinopathy. The final reference populations
included 9,946 children for the derivation of the hemoglobin curves and 2,314for the M C V curves. The
percentile curves should be particularly applicable to the diagnosis and screening of iron deficiency and
thalassemia minor.

Peter R. D a l l m a n , M.D.,* S a n Francisco, Calif., and

M a r t t i A. Siimes, M . D . , H e l s i n k L F i n l a n d

I R O N D E F I C I E N C Y is by far the most common cause of
a subnormal hemoglobin concentration; among many
ethnic groups, thalassemia minor is next in incidence. In
each condition, anemia is usually mild and there is
substantial overlap into the normal range. Iron deficiency
and thalassemia minor are also characterized by a
decrease in red cell volume. With the recent introduction
of electronic counters into large clinical laboratories, it has
become practical to determine the concentration of hemo-
globin and the red cell indices concurrently. By adding the
evaluation of mean corpuscular volume to the hemoglo-
bin determination, the reliability of diagnosis can be
increased substantially.
Values for both hemoglobin and MCV undergo marked
changes during development. In order to obtain reliable
reference standards, the reference population must be
screened to exclude iron deficiency and such relatively
common conditions as thalassemia minor. It is also
necessary to take into consideration the consistently lower
mean concentration of hemoglobin in blacks than in
whites and Orientals (about 0.5 gm/dl) that appears to be
From the Department of Pediatrics, University of
California, san Francisco, and the Children's
Hospital, University of Helsinki.
Supported by grants from the National Institutes of
Health, Grant No. A M HD 13897, and the
Foundation for Pediatric Research in Finland.
*Reprints address: 650-M, Universityof California Medical
Center, San Francisco, CA 94143.
independent of iron deficiency and thalassemia minor.'
Reference values for concentration of hemoglobin will be
lowered in proportion to the percentage of blacks that are
included in the reference population.
Abbreviation used
MCV: mean corpuscular volume
Most tabulations of hemoglobin concentration during
childhood show increases of 0.5 to 1.0 gm/dl from one age
range to the next. In screening healthy infants and
children, an error of 0.5 gm/dl can result in 10% of normal
individuals being incorrectly categorized as anemic. Fre-
richs et al'-' recently calculated the cost of ignoring the
relatively small hemoglobin difference between blacks
and whites. In a small Louisiana community, the cost of
following up the results of screening for iron deficiency in
1,000 white children would be $3,320, whereas $10,000
would be spent for 1,000 black children using the same
criterion for normal hemoglobin; the actual incidence of
iron deficiency was estimated to be equal in the two
groups. The incorrect classifying of "anemic" individuals
as normal is equally important.
In order to make optimal use of recent normative data,
we developed percentile grids for hemoglobin and m e a n
corpuscular volume versus age which are similar to the
familiar grids for height and weight. The curves were
derived from several populations of white children who

Vol. 94, No. l, pp. 26-31 0022-3476/79/100026+06500.60/0 9 1979 The C. V. Mosby Co.
Volume 94
Number I
lived near sea level and who did not include indigent
subjects. In all but one of the groups, additional laborato-
ry data allowed the exclusion of subjects with presumptive
evidence of iron deficiency, thalassemia minor, and/or
hemoglobinopathy.
METHODS
All values for hemoglobin and MCV were obtained on
venous blood by electronic counter (Coulter model S).
Hemoglobin values were derived from a total of 9,946
children, and MCV values from 2,314 children (after
excluding individuals who did not meet the criteria to be
included in the reference population). In the case of
hemoglobin, values for girls and boys were combined
between the ages of 0.5 and 9 years after finding no
consistent difference in concentration between the two
sexes. Data for MCV for boys and girls below the age of 7
were combined on the same basis.
The characteristics of the various groups were as
follows.
United States.
US I. This group of 1,358 white children, belonging to a
prepaid health plan, had a multiphasic health examina-
tion at the Kaiser Permanente Out-Patient Clinic in San
Francisco between 1973 and 1975. The ages were calcu-
lated to the nearest birthday and ranged from 5 to 14
years. For the calculation of hemoglobin percentiles, all
subjects with mean corpuscular volumes more than 5%
below the mezn for the same age and sex were excluded in
order to eliminate subjects most likely to have iron
deficiency or thalassemia minor. This criterion excluded
9.8% of the subjects. For the calculation of MCV percen-
tiles, all subjects with hemoglobin concentrations below
the twentieth percentile for the same age and sex were
excluded to eliminate subjects most likely to have iron
deficiency or thalassemia minor. Hemoglobin electropho-
resis was also used to exclude a very small number of
subjects (0.2% of the total) with hemoglobin S or C
trait.'
US IL This group of 7,489 white children was evaluated
in the Kaiser Permanente Multiphasic Program in San
Francisco, between the years 1970 and 1973. Ages for this
group were calculated to the nearest year and ranged from
5 through 16 years. Since the data for mean corpuscular
volume and hemoglobin electrophoresis could not be
readily retrieved, percentiles for hemoglobin were calcu-
lated from the entire group.
US III. This group is comprised of 210 white children
seen at the Moffitt Hospital Out-Patient Clinic in San
Francisco between 1974 and 1977. They fell into three age
categories: 10 to 17 months of age, 11/2to 4 years, and 4 to
7 years. For calculations of hemoglobin values, all those
Percentile curves for hemoglobin and red cell volume 27
17
16
15
14
13
G/D[
2 4 6 8 10 12 14 16
AGE, YEARS
Fig. 1. Hemoglobin concentration in boys. The third, fiftieth,
and ninty-seventh percentile curves and the individual points
from which they were derived are shown,
with serum ferritin values below 10 ng/ml, transferrin
saturation below 16%, and low MCV for age (less than 70
fl, less than 73 fl, and less than 75 fl in the three age
groups, respectively):~ were excluded. These criteria
resulted in 27% of the subjects being excluded, primarily
from the youngest age group and most frequently on the
basis of a low serum ferritin value, leaving a total of 158
children. MCV values were calculated after excluding
those subjects whose hemoglobin values were more than 2
SD below the mean by the above criteria, or who had
serum ferritin values below 10 ng/ml, transferrin satura-
tion below 16%, or abnormal hemoglobin electrophoresis.
Most of the subjects were included in one or both earlier
reports on developmental changes in the MCV ~ and
serum iron.;
Although 16% is commonly used as the lower limit of
normal for transferrin saturation in adults, the corre-
sponding value was recently reported to be 10% in infants"
and 7% in children below 12 years of age:'; in both studies,
subjects with low hemoglobin, MCV, and serum ferritin
values had been excluded. Nevertheless, we used the
value of 16% because of the poor reproducibility of the
serum iron concentration and the likelihood that some
iron-deficient individuals would have values overlapping
into the normal range.
Finland.
F 1. This group includes 777 children ~, about half of
whom were from a middle-class suburb in the greater
Helsinki area (Espoo); the other half were from a smaller
community in an agricultural area of central Finland
(Kiuruvesi). The suburban children constituted 50% and
28 Dallman and Siimes
GIRLS
G/DL
12
11
8~
8C
FL
7~
7(;
| 2 4 6 8 10 12 14 16
AGE, YEARS
Fig. 2. A, Hemoglobin and MCV percentile curves for girls. B, Hemoglobin and MCV percentile curves for boys.
the rural children 90% of the total populations of that age
in their respective communities. Children were studied in
1975 at age 2, 4, 7, 10, and 15 years to the nearest birthday.
For the calculation of hemoglobin values, 168 subjects
were excluded because they had a serum ferritin value less
than 10 ng/ml, a transferrin saturation less than 16%, or a
low MCV for age (less than 73 fl at age 2, less than 75 at
age 4, less than 76 at age 10, and less than 78 at age 15
years)? For the calculation of MCV values, subjects were
excluded if the value for hemoglobin was more than 2 SD
below the normal for the same age and sex after the above
exclusions, if the serum ferritin was less than l0 ng/ml, or
if the transferrin saturation was less than 16%.
F 11. In this group, infants were evaluated longitudinal-
ly, with 238, 228, and 238 subjects sampled at 6, 9, and 12
months (to the nearest month), respectively." ~ They were
seen at the well-baby clinic of the Helsinki Children's
Hospital. The criteria for excluding subjects prior to the
calculations of hemoglobin and MCV were the same as in
F I, except that subjects with an MCV below 70 were
excluded for the calculation of hemoglobin values. These
criteria resulted in the exclusion of 83, 69, and 84 infants
at 6, 9, and 12 months, respectively. These exclusions were
primarily on the basis of transferrin saturation.
The Journal q[ Pediatrics
January 1979
(~) 2 4 6 8 10 12 14 16
AGE, YEARS
STATISTICAL METHODS
All data were converted to percentiles with the e~cep-
tion of US IlI, in which the groups were small and the
mean _~ 2 SD were considered equivalent to the fiftieth,
ninety-seventh, and third percentiles.
Potentially iron-deficient or thalassemic individuals
could not be reliably excluded from group US II.
Nevertheless, these data were included because US If had
the advantage of being a very large group (7,489) of older
children who were beyond the peak age for iron defi~en-
cy, The fiftieth percentile values were very similar to or
actually higher than those of an analogous population
(US l) that was studied under identical circumstances in
1973 to 1976 instead of 1970 to 1973. In analyzing the data
from US I, we found that exclusion of subjects who did
not meet the criteria had virtually no effect on the median
hemoglobin value. Thus inclusion of US I1 was not felt to
be likely to exert a detectable downward bias in the data,
except perhaps at the third percentiles.
RESULTS
The derivation of third, fiftieth, and ninety-seventh
percentile curves for hemoglobin in boys is shown in Fig.
l, in which different symbols are used for the results from
Volume 94 Percentile curves for hemoglobin and red cell volume 29
Number I

the various groups. For clarity of presentation, the data Table

for the tenth and ninetieth percentiles are not shown.
There is very good general agreement in the fiftieth Hemoglobin
(gm/ dl) MCV (fl)
percentile values from the various populations. Hemoglo-
bin values in girls and MCV in both sexes were similarly Age Lower Lower
in close accord (complete figures corresponding to Fig. 1 @r) Median limit Median limit
are not included here but will be supplied on request). 0.5-2 12.5 11,0 77 70
Since one or two aberrant values can exert a strong 2-5 12.5 11.0 79 73
influence on the third and ninety-seventh percentile 5-9 13.0 11.5 81 75
values, it is not surprising to find more scatter among 9-12 13.5 12.0 83 76
12-14
these points. Percentile curves are shown without individ-
Female 13.5 12.0 85 77
ual data points in Fig. 2. The hemoglobin and MCV are Male 14.0 12.5 84 76
shown together for each sex to facilitate interpretation of 14-18
both laboratory results for individual patients. Values for Female 14.0 12.0 87 78
medians and lower limits of normal by age range were Male 15.0 13.0 86 77
18-49
derived from the fiftieth and third percentile curves,
Female 14.0 12.0 90 80
respectively, and tabulated in the Table as an alternative Male 16.0 14.0 90 80
to the developmental grids.
Values for MCV are plotted in a similar manner. Again,
there is close agreement among groups, especially at the common abnormalities or adverse environmental circum-
fiftieth percentile. Values for boys and girls are virtually stances that might be expected to bias the data. Although
identical, except that the rise in MCV occurs at a this method involves the use of criteria that might seem
somewhat earlier age in girls than in boys. There is greater arbitrary, it has certain advantages for the derivation of
variability at the third and ninety-seventh percentiles. normative data for hemoglobin and mean corpuscular
Values for MCV rise very gradually through most of volume. Iron deficiency is particularly prevalent between
childhood, with a median value of 84 to 85 fl at 15 years of the ages of I and 3, '~ and almost any sampling of this age
age that is still well below the adult value of about 90? group will include substantial numbers of children with
Some data indicate that MCV values do not reach a iron deficiency anemia. The prevalence of thalassemia
plateau even in the adult, but that they continue to minor will vary according to the ethnic make-up of the
increase throughout life. ~~ 11 population. Since normal standards are to be applied in
screening for these two common conditions, it is desirable
DISCUSSION that the standards are calculated after excluding as many
There are two general approaches to establishing crite- of these individuals as possible. The curves in the Figures
ria of normality; one involves studying a random sample represent an initial attempt to do this.
of the total population. This approach is exemplified by Any criteria that reliably exclude iron deficiency also
the recently published growth grids from the National exclude some iron-sufficient subjects. Indeed, the more
Center for Health Statistics that provide a standard sensitive the criteria are in respect to excluding iron
method for assessing growth of contemporary infants, deficiency, the less specific they are likely to be by also
children, and youth in the United States. 1..... One disad- excluding a larger percentage of the iron-sufficient popu-
vantage &these grids is that they do not exclude values of lation. Since it is likely that substantial numbers of
abnormal individuals. For example, body weight curves iron-sufficient children were excluded by our criteria, it is
reflect current conditions, with obesity a common abnor- important to ask whether the removal of this group biased
mality. Inclusion of obese individuals in the derivation of the reference data. In the derivation of normal hemoglo-
weight grids may be misleading if the curves are inter- bin values, for example, it was assumed that hemoglobin
preted as representing optimal standards. However, exclu- concentration and MCV are dependent variables only
sion of obese individuals or other abnormal categories when a condition such as iron deficiency or thalassemia
involves applying somewhat arbitrary definitions. Conse- minor results in both laboratory values being low. In the
quently, the use of height and weight values from a reference population, hemoglobin and MCV were consid-
random sample of the population is the least controversial ered to be independent variables. Although the latter is
method of obtaining growth standards. not strictly correct, it is close enough to the truth to be a
A second group of methods for deriving normative data reasonable working assumption. This was evident in US I,
involves the exclusion of all subjects with evidence of in which there was a very slight but significant tendency
30 Dallman and Siimes
for high MCV values to be associated with high hemoglo-
bin concentration at any given age.' Based on normalized
data from the entire group, we would predict that 10-
year-old white children, for example, with a higher than
average MCV of 86 fl would have a mean hemoglobin of
13.5 gm/dl; with a lower than average MCV of 78 fl there
would be a slightly lower hemoglobin of 13.4 gm/dl. Only
when the MCV fell below the presumptive lower limit of
normal of 76 (roughly corresponding to our exclusion
criterion) was there a much steeper and more substantial
fall in mean hemoglobin to 12.5 gm/dl. We felt it
legitimate to assume that MCV and hemoglobin were
independent variables within the reference population
because the hemoglobin concentrations were unlikely to
be altered by more than 0.1 gm/dl by excluding normal
subjects on the basis of our MCV criteria. The same
reasoning applies to the calculation of MCV after exclu-
sion of low hemoglobin values.
It could also be asked whether our criteria for transfer-
fin saturation and serum ferritin would bias the calcula-
tion of reference values for hemoglobin and MCV. In iron
deficiency, low transferrin saturation and serum ferritin
concentrations are associated with low values of hemoglo-
bin and MCV, but there is no evidence for a similar
correlation in iron-sufficient individuals. We compared
the mean serum iron in screened children of the three age
groups in US III whose hemoglobin, MCV, and serum
ferritin values, respectively, were below the median for
each test with those whose values were above the median.'
We found no significant difference in serum iron between
the high and low hemoglobin, MCV, and serum ferritin
values.
US I was previously part of a study of hemoglobin
values in whites, blacks, and Asians. As had been found in
other surveys, 1:'-~ blacks were found to have consistently
lower hemoglobin values by about 0.5 gm/dl.' This
difference should probably be taken into account in using
these grids. Data from a smaller number of Asians of
various ethnic backgrounds (primarily Chinese, Japanese,
and Filipino) were also analyzed, and there was no
evidence that their values were different from those of
whites after subjects with low MCV values were excluded.
MCV values in blacks may also be somewhat lower than
in whites? but the magnitude of this difference after
exclusion of thalassemia minor and iron deficiency has
not been determined.
A comparison with earlier published values indicates
that hemoglobin concentrations in this paper are higher
than previous tabulations of normal values at many ages.
Values at one year of age would be expected to be most
subject to error if they are based on a population with a
high prevalence of subclinical iron deficiency. In the large
The Journal of Pediatrics
January 1979
study of Guest and Brown, '~ the mean hemoglobin
concentration at 1 year of age was 11.1 gm/dl. Subsequent
tabulations from textbooks and surveys range from 11.2 to
12.0 gm/dl}' .~0-24all substantially lower than our median
value of 12.5 g m / d l ? Hunter and Smith z~ demonstrated
that exclusion of subjects with laboratory evidence of iron
deficiency substantially raised the distribution of hemo-
globin and hematocrit values in a group of healthy infants
of various racial groups. The fact that our values are
derived from a white population is an additional explana-
tion for the finding of higher values than in studies based
on a more racially heterogeneous population. Alternative
methods of deriving normative data for hemoglobin
involve excluding iron-deficient subjects by employing a
therapeutic trial of iron S. '-'~or assuming that hemoglobin
values in healthy populations follow a single Gaussian
distribution/'~
During adolescence, developmental changes in hemo-
globin or hematocrit are a function of the stage of sexual
maturation in boys. ~ It is possible to develop criteria of
normal for each stage of puberty, but the use of percentile
grids by age seems more practical for routine clinical use.
Differences in onset of puberty account for the large
spread between the third and ninety-seventh percentiles
for hemoglobin in boys.
For most laboratory studies, values are considered
subnormal when they are more than 2 SD below the
mean~ a lower limit that corresponds to the third percen-
tile. In the case of hemoglobin, it is recognized that there
is a large overlap between normal and subnormal val-
ues. ~..... For example, an individual may have a value that
lies in the lower portion of the normal distribution for his
sex and age despite having mild iron deficiency. This
individual, whose hemoglobin or hematocrit would
normally be higher, would not be recognized as being
"anemic" unless he were treated with iron. '-'~By combin-
ing the MCV with the hemoglobin in screening for iron
deficiency, '~ the accuracy of diagnosis is increased
because it is less likely that both values would be in the
lowest portion of the distribution curve by chance.'
In populations in which iron deficiency is common,
values for hemoglobin and MCV below the tenth percent-
ile might be considered grounds for suspecting iron
deficiency. However, in a population that contains few
iron-deficient individuals, criteria should probably be
more stringent because it is difficult to justify investigat-
ing too many normal children in the lower part of the
normal distribution curve in order to discover every
example of mild deficiency. The statistical considerations
in evaluating these two types of populations are applica-
ble to many screening situations? ~ The beneficial results
of treating iron deficiency and counseling individuals with
Volume 94
Number 1
thalassemia m i n o r m u s t be b a l a n c e d against the cost a n d
inconvenience of the screening p r o c e d u r e to n o r m a l
subjects.
Our d e v e l o p m e n t a l grids for h e m o g l o b i n a n d M C V are
a n attempt to deal with currently available data. As more
c o m p r e h e n s i v e survey data b e c o m e available, a n d with
verification o f reference values by t h e r a p e u t i c trial with
iron, it is likely that a d j u s t m e n t s a n d modifications will
have to be made.
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